Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 44
The most common cause of hemoptysis worldwide: a fluke?
Amritpal Nat, MD, Amitpal Nat, MD, Amit Sharma, MBBS, MPH, Ghanshyam Shastri, MD, and Michael C. Iannuzzi, MD, MBA
Global travel is associated with an increasing incidence of helminthic
infections in nonendemic regions. We describe a patient with recurrent
hemoptysis from a chronic infection not commonly found in the USA.
CASE PRESENTATION
A 20-year-old healthy female college swimmer was referred for evaluation of intermittent episodes of hemoptysis
for 1 year. She had one to two episodes every other week
of quarter-sized hemoptysis associated with dyspnea. Her
symptoms began after a dive 3 meters above the pool resulting in a “belly flop.” Her vital signs and complete blood
count with differential we re within normal limits, and her
initial radiograph was normal. Computed tomography (CT)
showed two cystic lesions in the right lower lobe (Figure 1).
The patient denied alcohol, cigarette, or illicit drug use. She
had traveled to Costa Rica and the Bahamas 1 year earlier.
Bronchoscopy with bronchoalveolar lavage, brushings, and
CT-guided biopsy were unremarkable. Cultures from the
bronchial washings and the cytology were negative. Pulmonary function tests were normal. Workup for connective tissue disorders was negative. Further evaluation for pulmonary
tuberculosis, mycoplasma, histoplasmosis, and blastomycosis
was negative.
Subsequent CT scans showed interval resolution and redistribution of the cystic lesions (Figure 2). Paragonimus westermani
antibody titers were obtained 1 year after the initial presentation
and were elevated at 1:32. The diagnosis of chronic pulmonary
paragonimiasis was made, and the patient responded well to
praziquantel (1, 2).
DISCUSSION
The presentation of hemoptysis after diving with the
finding of cysts on chest CT led to a consideration of
traumatic pneumatocele. Given the relatively mild chest
injury at the time of the dive, the resolution and recurrence of the lung parenchymal cysts, and the recent travel
history, an infectious etiology was more likely. Although
stool, sputum, and bronchial washings for ova and parasites
118
Figure 1. CT thorax showing thin-walled cysts within the parenchyma of the right
lower lobe. This represents a late radiologic finding of pulmonary paragonimiasis.
were negative, Paragonimus westermani titers were elevated.
Serologic testing for anti-Paragonimus IgG has a sensitivity
of nearly 100% and a specificity of 91% to 100% (3).
Paragonimus westermani, also known as the lung fluke, is
acquired through the ingestion of raw/undercooked crabs or
crayfish. It is the most common cause of hemoptysis worldwide (4). Diagnosis can be challenging, and clinicians should
be alerted to the sensitivity and specificity of serologic testing. Treatment involves a 3-day course of praziquantel with a
response rate of 100% (5). This clinical vignette underscores
the importance of health care providers in the USA recognizing
common worldwide infections.
From State University of New York Upstate Medical University, Syracuse,
New York.
Corresponding author: Amritpal Nat, MD, State University of New York
Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210-2375
(e-mail: [email protected]).
Proc (Bayl Univ Med Cent) 2014;27(2):118–119